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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603509
Report Date: 09/06/2023
Date Signed: 09/06/2023 01:08:38 PM


Document Has Been Signed on 09/06/2023 01:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:WESTMONT AT SAN MIGUEL RANCHFACILITY NUMBER:
374603509
ADMINISTRATOR:ROSSI, MARIAFACILITY TYPE:
740
ADDRESS:2325 PROCTOR VALLEY RDTELEPHONE:
(619) 271-4385
CITY:CHULA VISTASTATE: CAZIP CODE:
91914
CAPACITY:105CENSUS: 86DATE:
09/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Michael Sokolowski, Executive DirectorTIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA), Carmen Lopez conducted an unannounced visit to open a complaint investigation and conjointly conducted a case management visit for review of resident records. LPA identified herself and was granted entry by Executive Director Michael Sokolowski. LPA stated the purpose of the visit and reviewed the basic elements of the visit with Executive Director Sokolowski.

On Wednesday, September 6, 2023, LPA Lopez initiated a complaint investigation that was submitted to the Department on August 29, 2023, for investigation. During the visit, LPA reviewed residents’ documentation and observed that resident #1 (R1’s) Physician’s Report (LIC602) was outdated.

Based on records reviewed and LPA’s observations, it was determined that the facility did not keep R1’s LIC602 updated. The facility is being issued technical violation and can be found on the LIC 9102TV.

An exit interview was conducted with Executive Director Michael Sokolowski and Brittany Blaul, Resident Service Director. A copy of this report along with Licensee/Appeal Rights (LIC9058 03/22) were provided to Executive Director Sokolowski at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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